Health inspection·November 15, 2019

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with the DON on [DATE] at 7:53 a.m., the DON confirmed medication should be taken out of the medication cart when it's been discontinued. 3. A vial of Humalog (used to regulate insulin in the blood) was expired. During a medication cart audit with registered nurse (RN H) on [DATE] at 10:16 a.m., a vial of Humalog insulin with an opened date of [DATE] was found in the medication cart. RN H confirmed that Humalog insulin was stored passed 28 days. During an interview with the DON on [DATE] at 7:54 a.m., the DON stated insulin should only be kept inside the medication cart no longer than 28 days. A review of manufacturer's guideline for Humalog insulin indicated, throw away open vials 28 days after first use. 4. Licensed vocational nurse I (LVN I) left Brimonidine 0.2% (used to relieve redness in the eyes caused by minor eye irritations.) on top of the cart unattended. During an observation with LVN I on [DATE] at 4:16 p.m., LVN I left Brimonidine 0.2% on top of the cart unattended. LVN I confirmed she should not leave medication on top of the cart unattended. During an interview with the DON on [DATE] at 7:50 a.m., the DON stated medication should not be left of top of the cart unattended. A review of the facility's policy, Administering Medication, indicated no medication are left on top of the cart. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555156 If continuation sheet Page 2 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555156 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Webster House 437 Webster Street Palo Alto, CA 94301 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0790 Provide routine and 24-hour emergency dental care for each resident. Level of Harm - Minimal harm or potential for actual harm Based on interview, and record review, the facility failed to ensure a follow up was made in a timely manner for a missing denture for one of two sampled residents (6). Resident 6' s upper denture was missing and Resident 6's insurance denied to replace. These failures caused a delay in Resident 6 receiving the necessary dental services and could negatively affect Resident 6's physical comfort and psychosocial well-being. Residents Affected - Few Findings: Review of Resident 6's clinical record indicated she was admitted to the facility with a diagnoses including hemiplegia (affecting one side of the body) following cerebral infarction (stroke). Review of Resident 6' Progress Notes dated 8/6/19, indicated Resident 6's upper denture was not taken by a family member (FM) and would be evaluated by a dentist for possible replacement. Resident 6 was also seen by the dentist on 8/23/19, and recommendation was to have a full set of dentures (upper and lower). Review of the facility's theft and lost binder indicated Resident 6's full upper dentures was missing on 8/6/19. It also noted, on 10/22/19, Resident 6 was denied by the insurance for full set of dentures. Another referral to Resident 6's insurance was made on 10/23/19. Review of Resident 6's insurance notice of action dated 10/18/19 indicated the replacement was denied due to Resident 6's no longer in the facility. During an interview with Resident 6's FM on 11/12. /19 at 11:45 a.m. The FM stated he had concerns about what happened to Resident 6's upper dentures. The FM stated he received a letter of denial from Resident 6's insurance sometime in October 2019. During an interview with licensed vocational nurse E (LVN E) on 11/13/19 at 7:48 a.m. LVN E confirmed Resident 6' s upper denture was missing since August 2019. During an interview with the DSS on 11/13/19 at 7:58 a.m., the DSS confirmed Resident 6's upper denture was missing on 8/6/19. The DSS stated the dentist recommended replacement of upper and lower dentures, and a referral was submitted to Resident 6's insurance. The DSS stated the facility could only pay for the upper denture.The DSS acknowledged the insurance denial notice did not have the right information as Resident 6 was an active resident in their facility .The DSS stated the dentist had to resubmit another referral to the insurance after the denial. During an interview with the director of nursing (DON) on 11/13/19 at 8:20 a.m., the DON stated the facility should replace Resident 6' s full set of dentures regardless of the insurance, FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555156 If continuation sheet Page 3 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555156 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Webster House 437 Webster Street Palo Alto, CA 94301 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure a cook utilized standardized recipes for puree (smooth texture) food preparation to ensure nutritive value. This failure resulted in the residents prescribed puree diet being placed at an increased risk for nutritional impairment. Residents Affected - Some Findings: During a concurrent observation and interview with lead cook (LC) on11/14/19 at 9:53 a.m., LC was adding water inside a container with biscuits inside. LC stated she used water when pureeing biscuits. During a review of recipe with the dietary manager (DM) on 11/14/19 at 10:15 a.m., puree recipe for buttermilk biscuits indicated, blend biscuits with milk in Robocop, blender or food processor until smooth. During an interview with registered dietician A (RD A) on 11/14/19 at 10:22 a.m., RD A confirmed changes in nutrients of the biscuits could occur when diluted with water instead of milk. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555156 If continuation sheet Page 4 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555156 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Webster House 437 Webster Street Palo Alto, CA 94301 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. 4. During a trayline observation of the fourth floor, together with the dining services manager (DSM) on 11/12/19 at 12:15 p.m, licensed vocational nurse E (LVN E) looked at trays crossing the yellow line without a hair net. An activity staff (AS) went inside the kitchen through a closed door without a hair net. Certified nursing assistant F (CNA F) looked in the refrigerator and was holding a tray and crossed the yellow line without a hair net. During a concurrent interview with the DSM, she acknowledged facility staff should wear a hair net when crossing the yellow line.Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared and served under sanitary conditions when: 1. Bin used to store flour was unlabeled; 2. Scoop utensil was lying on top of the thickener bin; 3. Ice machine spout was dirty; 4. Staff crossed yellow line (division between kitchen and dining area) during trayline without hairnets; 5. Beef meat loaf was held for service at 140 F (F, fahrenheit, unit of temperature). This failure had the potential for occurrence of food-borne illnesses. Findings: 1. During an observation on 11/12/19 at 8:21 a.m., with the dietary manager (DM), a bin with dry food powder was observed under the kitchen sink. During an interview with the registered dietitian A (RD A) on 11/15/19 at 3:18 p.m., RD A stated the flour should have a label. 2. During an observation on 11/12/19 at 8:23 a.m., there was a scoop lying on top of thickener container. The DM stated it was ok for the scoop to be stored on top of the container. During an interview with RD A on 11/15/19 at 3:18 p.m., the RD A stated the scoop should be stored in a different container. Acccording to the FDA 2017 Food Code, Section 3-304.12 In-Use Utensils, Between-Use Storage shall be stored with their handles above the top of the food. 3. During an observation with the building maintenance director (BMD) on 11/15/19 at 1:40 p.m., unit 2's (2nd floor) ice machine had whitish, brownish discoloration in the plastic chute (where the ice comes out). The BDM stated it was a calcium build up. According to Food Code 2017 as specified in paragraph 4-602.11 indicated water vending equipment, ice makers should be cleaned on a routine basis to prevent the development of slime, mold, or soil (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555156 If continuation sheet Page 5 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555156 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Webster House 437 Webster Street Palo Alto, CA 94301 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 residues that may contribute to an accumulation of microorganism. Level of Harm - Minimal harm or potential for actual harm 5. During an observation and interview with dietary staff J (DS J) on 11/12/19 at 12:02 p.m., he measured the temperature of the meat loaf prior to starting tray line: DS J stated the meatloaf temperature was 140F and recorded it on the temperature log. Residents Affected - Some During an interview with registered dietitian A (RD A) on 11/14/19 at 10:57 a.m., she stated the meat loaf served for lunch on 11/12/19 was made of ground beef. During an interview with RD B on 11/14/19 at 1:18 p.m., she stated the holding temperature for meat loaf or ground beef was 140 F According to CDC and federal guidelines, indicated monitoring the food's internal temperature is important and will help ensure microorganisms can no longer survive and food is safe for consumption, ground beef should be held for service at 155 F. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555156 If continuation sheet Page 6 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555156 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Webster House 437 Webster Street Palo Alto, CA 94301 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure staff implemented the infection control practices when: Residents Affected - Few 1. Treatment nurse C (TXN C) did not perform hand hygeine while providing wound treatment; 2. Certified nursing assistant D (CNA D) disposed dining ware of a resident in the isolation room; 3. Licensed vocational nurse E (LVN E) failed to perform hand hygeine between different medication routes. These failures had the potential to put vulnerable residents at risk for infection. Findings: 1. During a wound treatment observation with TXN C on 11/14/19 at 12:00 p.m., TXN C performed wound treatment on Resident 24's right lateral foot. TXN C confirmed she wore at least two layers of gloves on each hand while treating Resident 24's wound, removing each layer as she cleaned and dressed the wound. During an interview with the director of staff development (DSD) on 11/15/19 9:17 a.m., he stated using multiple layers of gloves and removing layer by layer during wound treatment should not be done. Licensed nurse need to apply hand hygiene every time they wear or remove gloves. During an interview with the director of nursing (DON) on 1:52 p.m., she stated using multiple layers of gloves and removing them layer by layer is a big no no. Staff should not do that. Review of the facility's policy and procedures, Pressure Ulcer Treatment, indicated put clean gloves on after washing and drying hands completely before and after removing wound dressing, opening wound treatment equipment, cleansing the wound. 2. During an observation on 11/13/19 at 9:01 a.m., CNA D carried a breakfast tray out of Resident 152's room. CNA D was not wearing any PPE. CNA D then opened the dining room/ kitchen door and discarded the used disposable dining ware on to the kitchen trash with her bare hands. CNA D then opened the dining room/kitchen door and opened the utility room door to wash her hands. During a concurrent interview with CNA D, she stated the tray was from Resident 152's room. Resident 152 was on isolation precautions. She confirmed she disposed the disposable dining ware in the kitchen with her ungloved hands. During an interview with the DSD on 11/14/19 at 12:59 a.m., he stated Resident 152 was on isolation precautions. Staff need to wear disposable personal protective equipment (PPE, equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) - such as gloves, gown, mask when entering Resident 152's room. PPE and other items used by the resident need to be discarded in the biohazard bin inside the resident's bathroom. The DSD further stated CNA D broke the infection control chain when she went outside Resident 152's room and disposed Resident 152's used dining ware in the kitchen; She should have not done that. CNA D should have thrown the dining ware in the biohazard bins inside Resident 152's room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555156 If continuation sheet Page 7 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555156 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Webster House 437 Webster Street Palo Alto, CA 94301 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm 3.During a medication pass observation with licensed vocational nurse E (LVN E) on 11/14/19 at 9:10 a.m., LVN E used the same gloved hand to administer eyedrop, nose spray, and inhaler for Resident 66. During an interview with LVN E on 11/14/19 at 9:18 a.m., LVN E confirmed she did not perform hand hygiene in between administering eye drop, nose spray and inhaler medication for Resident 66. Residents Affected - Few A review of the facility's policy Administering Medication, dated 10/13/11, indicated staff shall follow established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) when these apply to the administration of medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555156 If continuation sheet Page 8 of 8